Diagnosis And Management

Due to the high solubility of CO2, in the select clinically stable patient with pneumothorax, pneumopericardium, and pneumomediastinum expectant management including close monitoring and serial chest X-rays is advocated.

Subclinical gas collections in the chest are usually asymptomatic, and require no further intervention. These abnormal chest gas collections are incidentally detected on routine postoperative X-ray. Perhaps in the early laparoscopic experience, all patients should undergo chest X-ray routinely in the recovery room. However, with evolving experience, postoperative chest X-rays should be obtained selectively only if there is any clinical suspicion of a thoracic complication, according to the patient's clinical status.

Clinically significant pneumothorax may require intraoperative or early postoperative intervention.

Routine postoperative chest X-ray may reveal an extensive pneumothorax with lung collapse requiring a thoracostomy tube. Intraoperatively, sudden hypotension or decrease in O2 saturation may represent alert signs of a large pneumothorax. Therefore, cooperation between the anesthesiologist and surgical teams is crucial for the precise diagnosis of this complication. Filling the operative field with irrigation fluid can identify air bubbles coming from an inadvertent pleurotomy. A red rubber catheter can be inserted directly into the pleural space and figure-of-eight stitches can be placed laparo-scopically to repair the pleural injury around the red rubber catheter, which is attached to continuous water-seal suction. Alternatively, the diaphragmatic rent can be laparo-scopically suture repaired with the pneumoperitoneum pressure decreased to 5 mmHg and the anesthesiologist providing positive ventilatory pressure. In the Cleveland Clinic study, two patients developed large pneumothoraces recognized only postoperatively, necessitating chest tube drainage. In both cases, although no frank pleural or diaphragmatic injury was detected intraoperatively, the authors cannot rule it out (1). Similarly, in an open series of 253 flank procedures, two patients developed postoperative pneumothorax without any intraoperative recognition of pleurotomy (6). As such, a high index of suspicion should be maintained because pleural or diaphragmatic injury may not always be recognized intraoperatively.

Rare thoracic surgical complications such as hemothorax and chylothorax have also been reported (1). Acute hemothorax occurred following a retroperitoneoscopic kidney tumor cryoablation. Because of the particular body habitus and obesity (body mass index = 36) of this patient, bony landmarks were difficult to palpate resulting in undiagnosed supracostal placement of the posterior port. Following cryoablation, in the recovery room, the patient was hypotensive, and a chest X-ray demonstrated "whiteout" of the left hemithorax. A tube thoracostomy was inserted with return of fresh blood. An emergency open thoracotomy identified an intercostal arterial bleeder which was suture ligated. Additionally, a 3 cm diaphragmatic rent created by the supra-costal port was identified and suture repaired.

Following synchronous bilateral retroperitoneal laparoscopic native nephrectomy for locally symptomatic, huge, autosomal dominant polycystic kidneys, a patient returned to the emergency room complaining of sharp left pleuritic pain with mild shortness of breath. A chest computed tomography scan revealed a large left pleural effusion causing collapse of the left lower lung. Abdominal computed tomography did not reveal any retroperitoneal fluid collection. Pleurocentesis retrieved 300 cc of milky chylous fluid high in chylomicrons and triglyceride. This chylothorax was successfully treated conservatively with low fat diet and medium-chain triglyceride supplementation.

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